MCCG212 - Reimbursement Methodology Report

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Bryant & Stratton College *

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Dec 6, 2023

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MCCG212 – Advanced ICD Diagnostic Coding Week 7 Reimbursement Methodology Report – Alexus Robinson Part 1:

MCCG212 – Reimbursement Methodology Report Template 2 Reimbursem ent System Outpatient Surgery Center Hospital Inpatient Laboratory Services Prescription Drug Medicare Ambulatory Procedure Codes (APCs) via Outpatient Prospective Payment System (OPPS) - Physician Bills Separately. Each APC averages a number of individual procedures into a single number Prospective Payment System (PPS) with MS-DRGs. Lump-sum payment for entire hospital stay. - Private physicians bill separately Fee Schedule Medicare Part D Drug Plan or Out-of-Pocket. Some drugs are covered by Medicare Part B (physician services)-- especially things like vaccine and other injection Medicare Advantage (Managed Care) Part C Monthly Lump-Sum Payment for all patient care Lump-sum payment for entire hospital stay Monthly Lump-Sum Payment for all patient care Monthly Lump-Sum Payment for all patient care Medicaid Each APC averages a number of individual procedures into a single number. Acute hospital inpatient reimbursemen t rate parameters have been rebased according to 12VAC30-70- 391. For Type Two hospitals, the new base rates should result in total expenditures that reimburse on average 78% of acute and rehabilitation operating The Deficit Reduction Act of 1984 requires Medicare to establish fee schedules for clinical laboratory procedures, including specimen handling and collection. Federal regulations (42 CFR 447.342) limit Medicaid reimbursemen t to no more Medicare Part D based on formulary and non rates or by the states payment system.

MCCG212 – Reimbursement Methodology Report Template 3 Part 2: Each reimbursement system is different but some do have similarities. Medicare and Medicare Advantage both follow the same processes all the way across the board. One key difference is that you have some systems that differentiate between states payment system and you have commercial insurance base reimbursement off of negotiated prices. With the Fee-For- Service (FFS) model under Medicaid each service receives a specific reimbursement in exchange for the services rendered. FFS rates are designed to pay doctors only for the care that an individual has specifically received. Commercial coverage usually has a wider range of plans versus Medicare. If I were a medical provider I would choose to work with the commercial insurance reimbursement system, specifically PPO’s. They usually offer a network of physicians but also give patients flexibility in not requiring referrals to specialist. Commercial insurances usually cover a fair amount of healthcare costs which will lower the amount that the patients are expected to pay. One challenge I may face is collecting copayments from patients but that is something that we can overcome by collecting the co pay up front before the patient is seen. Another difficulty may be the rates set by certain companies. For example some companies may have lower reimbursements that I wouldn’t find acceptable.

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MCCG212 – Reimbursement Methodology Report Template 4 References

MCCG212 – Reimbursement Methodology Report Template 5 Health Care Reimbursement. (2022, August 8). John Hopkins Sheridan Libraries . https://guides.library.jhu.edu/heath-care- reimbursement/find-amounts (n.d.). Medicaid.gov: the official U.S. government site for Medicare | Medicaid. https://www.medicaid.gov/

MCCG212 - Reimbursement Methodology Report

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